A last-minute deal to expand Medicaid in Missouri almost materialized in the waning days of this year’s legislative session, briefly breathing life into an issue that had seemed all but doomed.

Missouri State Sen. Ryan Silvey, a Kansas City Republican, provided a behind-the-scenes look at high-level negotiations that occurred just before the session ended without an agreement to expand Medicaid eligibility.

The last-minute talks – which Silvey says included a meeting between himself, GOP leaders from the House and Senate, and Gov. Jay Nixon – appear to have moved the issue of Medicaid expansion closer to the finish line than it has ever been since the debate began two years ago.

“I was encouraged that there was even a push for last-minute negotiations,” he says. “I think that tells you how close we were.”

Currently, Missouri limits Medicaid eligibility to nonelderly adults earning no more than 19 percent of the federal poverty level. As contemplated under the Affordable Care Act, expansion would mean extending it to those with incomes up to 138 percent of the poverty level.

In Missouri, that translates into 300,000 more people on the Medicaid rolls. Federal funding would cover 100 percent of the costs for the first three years and 90 percent afterward.

A late-session deal between Democrats and Republicans on abortion and labor issues opened the door for the talks about Medicaid expansion and entitlement reform, Silvey says.

“We basically found ourselves with most of the week left and all of the major issues dealt with except for this and some of the labor stuff,” he says. “The thought was, now that we’ve got all this time, we might as well see if we can get to a deal on those things, and that is why we began the last-minute push.”

Deal called for labor and abortion concessions
The outline of the deal that emerged, Silvey says, would have given Democrats Medicaid expansion and given Republicans entitlement reform and some additional measures opposed by labor unions. Silvey didn’t provide details on the labor discussions, since, he says, he was more focused on entitlement reform.

The meeting broke up, Silvey says, with members of the GOP leadership pledging to run the framework of the plan past rank-and-file members of their party in both chambers.

An hour or two after the meeting, though, House Majority Leader John Diehl, of Town and Country, told Nixon that the outline would not pass muster in the House, Silvey says.

Attempts to reach Diehl and House Speaker Tim Jones, of Eureka, through their legislative offices were unsuccessful.

Expansion would bring in billions of dollars in federal matching funds between 2014 and 2020. In addition, the state estimates it would save millions of dollars in state funding by shifting medical costs to Medicaid recipients who would largely be covered by the federal government.

Silvey says his plan would have put those projected savings into a fund providing the state match once the federal government ceases covering the full costs of newly eligible Medicaid recipients.

And, under a key provision of his plan, providers would bear the brunt of the burden if the fund becomes insolvent by seeing their reimbursements reduced. Silvey says his reasoning was that providers such as hospitals and community health clinics would stand to gain a lot financially by having more patients covered through insurance.

That protection for the state has “opened the eyes of a lot of my colleagues,” Silvey says.

Silvey also says his proposal was unique in placing job-search requirements on recipients of entitlement programs that overlap with Medicaid eligibility. That way, he says, Missouri could overcome federal objections to placing work requirements on Medicaid recipients.

He predicts that his plan and a similar House proposal will provide the basis of renewed debate when the General Assembly reconvenes next year.

Hope for 2015
“I did have a few of my Republican colleagues tell me that they thought we needed to do something and they would be willing to help next year,” Silvey says.

The Missouri State Medical Association (MSMA) is among a number of statewide groups supporting Medicaid expansion, and the organization’s director of government affairs and general counsel, Jeff Howell, agrees that proponents made strides in this year’s legislative session.

“I think the ball is rolling in the right direction for 2015,” Howell says.

Although the House apparently pulled the plug on any last-minute deal this year, the Senate has been a sticking point for Medicaid expansion proponents.

Howell says the makeup of the Senate might be more favorable next year with the departure of members through term limits or decisions not to seek re-election. But, he adds, “Each session is an individual beast. You just never know.”

The MSMA represents physicians, and Howell also says the organization is pressing for Medicaid expansion to include a rate increase. Missouri Medicaid reimburses at about 60 percent of what commercial insurers pay, he says.

Having a lot of newly eligible customers through expansion would not benefit physicians if the dollars and cents don’t add up, he says.

“If it’s not worth their time, they are not going to see (Medicaid patients),” he says. “It is just as plain as that.”